AIRP Site Training Information Form

You may apply for the UW AIRP site training programs conducted at the University of Wisconsin Hospital and Clinics in Madison, WI, by completing the form below. PDF versions are also available on the individual training pages.

Training Information

Check the boxes for which you would like to apply for site training, and select from one of the training dates below.:

UBART research site training

May 11 & 12, 2007
October 26 & 27, 2007

CIMT research site training

April 20 & 21, 2007
July 20 & 21, 2007
October 19 & 20, 2007

CIMT clinical use training

April 20 & 21, 2007
July 20 & 21, 2007
October 19 & 20, 2007

Identifying Information

Site name (e.g., University Hospital):

Name of contact person:

Title of contact person (e.g., physician, sonographer):

Name of supervising physician:

Contact Information

Street:

City: State:

ZIP Code:

Phone number:

FAX number:

E-mail address:

Training Information

How many people do you want to train?

Whom do you want to train?
Please include their name and degree(s). Additionally, note whether they need training in scanning (“Scan”) and reading (“Read”), whether they are registered (“Reg.”, e.g., ARDMS), and how many years of experience they have had (“Exp.”).

Trainee’s name
Degree(s)
Scan
 Read
Reg.
Exp.

Information about your ultrasound machine:
Make:
Model:

Information about your ultrasound transducer:
Model:
Type:
Frequency:

If you intend to read the UBART or CIMT exams, what software will you use?

Subject populations you will be studying (age range, disease state, etc.).

Has anyone else from your practice attended this course?
Yes
No

If yes, please the name of the person who attended:
Please include the dates of the person's attendance:

Any other information you think would be useful for us to plan your training session:

Enter this text into the box below

Confirmation Code (required*) (what is this?)
(* enter the 5-digit number from the image above into the box below)

You must enter the 5-digit confirmation code from the image, before clicking on Submit.
Note: Click the Submit button only once, then wait about 10 secs for a response

Clicking “Submit” will send your information to:
Us.

AIRP HomeSchool of Diagnostic Medical SonographyThis page was designed and is maintained by Nersi Nikakhtar.
Last updated Aug. 13, 2007